HomeMy WebLinkAboutMiscellaneous - 398 Andover StreetTOWN OF NORTH ANDOVER
,APPLICATION FOR PLAN EXaMlN:XTIUN
�sscMus�
Permit VO:--7� Date Received: r � 6
Date Issued: L6-
IMPORTANT: Applicant must complete all items on this
LOC.%,TION `� A.<7L
Print/ �1
PROPERTY OWNER ��An/
Print
MAP NU.:_PARCEL ZONING DISTRICT:
TYPE AND USE OF BUILDING
TYPE OF IMPROVEMENT
New Building
Addition
Alteration
Repair, replacement
= Demolition
Moving (relocation)
Foundation only
DESCRIPTION OF V
OVv''N, ER
Address:
HISTORIC DISTRICT YES ❑
PROPOSED USE
Residential Non- Residential
One family � -
= Two or more family =Industrial
No. of units:
Assessory Bldg _Commercial
= Other Others:
TO BE PREFORMED
411_° cis.
r
Identification //Please Type or Print Clearly)
?Mame:
�i��gr/ G-�t� Phone:
CONTRACTOR Marne
rJ -
;address: /.� �D�y�L Aek;;7 /Z/-/9 1 032 29
Super% isor's Construction License:
Exp. Date:
3 /— 70 0-7
Home; [mproNement License:
Exp. Date: S—v� X07%
;.RCHITECT I N- NEER \.ame: C'hcne:
kcidress:
Reg. No.
FEE SCHEDL LE: 3C LDI.NG P£'R,N/T: SI o. %o PER si'100.06 OF THE TOT IL EST1.11-1 TED COST 3ASED Opti PER F. F.
Total Project C OSt :$_- !2qfg-� xI0.00= FEE: 4 .moo
Check No.: // 5 - Receipt '�'o.: _L__L__ 3
"5",
Location 5"76?
No. -7 n Date
TOWN OF NORTH ANDOVER
FEW
Mu
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #/ / S-�
19237
Building Inspector
n'PE OF SE\k',%RGE DISPOSAL
_
Tanning Alassage Body .art
Sti imming Pouts
Public Seer
_
Well _
Tobacco Sales —
Food Packaging Sales
_
Permanent Dempster on Site _
Private (septic tank, etc. _
Electric deter location to
project
.NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fi nd
Signature of Agent, Owner Signature of Contract ` 1/z�
Plans Submitted - Plans Waived Certified Plot Plan Stamped Plans _
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
.,0 HEALTH
011
CONItitENTS
DATE REJECTED DATE APPROVED
❑
[]Water Shed Special Permit
�I Site Plan Special Permit
Other
DATE REJECTED DATE APPROVED
U i10
DATE REJEC'T'ED
Zoning Board of Appeals: % ariance. Petition No:
Zoning Dccision: receipt -<itbmittcd , cs
Planning 8•rard Pecision: , nmmcnt:;
t cr 1tic11 Dc'.J.Jon: �_.�mnunts
V,tcr.'c ti (x J!'ncction illtt.rl L �atl
_inp Dempster cn , itc , c:s____ ( =ire Dvpartmcnt Li-,natur,_ Jaw
Building flcrmit Appro%cd and ISSLIt;d by:
DATE :APPROVED
r -
HOMEOW B SS/CUSTOMER INFORMATION CONTRACTOR INFORMATION
Name47
ivc- EVC Construction
Street Address (not PO Box) 39 &�Erik V. Croto
City/Town/�/ /r vt/� p State /3 Zip code 0 �l J 159 Brady Avenue
Daytime Phone 17)9-- EG/IV?
Phone-5'7,S'—Ze 77 ,2B%.;'Salem, NH 03079
Mailing Address (if from above.) _ (603) 231-7207 Federal Employer lel# 90-006-3653
Salesperson(s) C— MA Contractor Registration # 138877 Exp. Date
. ,:r < t{•_ iSt�i�t s+:i l�'!} °};�.;T 'e9,'s"sS t'.ri.: > .tt f>>.. i, F. -.dg
Contrac} Agrees to do the Following Work for Homeowner-
:4
omeowner:�i�/�c2 <'P�%?.Q G�o��� P �ii,�✓9 A iP��I P Sic�� ri 7` d�� �ir1a
Materials Expected to be
Used- //� % //� / J�
(/I_ ) l,-, / PL iq/2 ( /v�6?lL7/Z/// /F?/N.vly/./� / 1/L'_ �
The following schedule will be adhered,#ounl�ss,circumstances beyond the contractor's control arise: n
Work Scheduled to Begin: k 6 {� / Oce Expected Date of Completion: &* 07' Q 0�
The contractor agrees to perform the work, furnish the material and labor specified above for the SUM of $ 7
Payments will be made according to the following SCHEDULE: $ v-1rupon signing contract
$ by or upon completion �' t dam'
$ a9 Siby or upon corn lotion S�e�0, f
$ i 3,29,S by —' or upon completion of the Contrac
In order to meet the completion schedule, the follo " g materiaUequipment must be special order ore the contracted work begins. $ / 3 -2,9 1 J 7 to
be paid for _
;t-_ .,�j-..,ii,4 ttt�! �->'iilt�k€ ti' >ilt�%1'. ;�iF 't�siS�t..s.,;t*,. '+,i !•''•
Homeowner's Signature X Date OG Contractors Signature - /. �� Date 5/- /-3- v b
You may cancel this agreemen�1, it h by a party th to at a place other than an address of the seller, which may be his main office or brunch
thereof, provided you notify thin wri ' g at his main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight of
the third business day followinsigning of the agreement.
rs•s)t itdt'.1i1'k.F2�',tti4
The following building permits are required. It is the obligation of the contractor to secure such permits as the homeowner's agent:
NOTE: Owners who secure their own permits or deal with unregistered contractors are excluded form the Guaranty Fund Provision MGL. C. 142A.
Is an EXPRESS WARRANTY being provided by the contractor? NO YES _. All terms of the warranty must be attached to the contract Home
Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 617-727-8598
Unless otherwise noted within this document, the contract shall not imply that any lien or other security interest has been placed on the residence.
'1011 e i� q : k 3 ,,
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may
submit such dispute to a private arbitration- set -vice which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business
Regulations and the consumer shall be required to submit to such arbitration as provided by M.G.L. c. 142A
Contractor: Date Homeowner: Date
NOTICE: TIS SIGNATURE S OF TIF PARTIES ABOVE APPLY ONLY TO TIS; AGREEMENT OF ITIS PARTIES TO ALTERNATIVE DISPUTE
SETTLEMENT INITIATED BY THE CONTRACTOR. THE OWNER MAY INITIATE ALTERNATIVE DISPUTE IT-,-SULUTION EVEN WIR RF. "PHIS
SECTION IS NOT SEPARATELY SIGNED BY THE PARTIES.
Homeowner's Financial Insecurity- A Contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially .insecure.
Contractor's Financial Insecurity- In instances where a contractor deems him/herself to be financially insecure, the contractor may require that the balance of
fiends not yet due placed in a.joint escrow account as a prerequisite to continuing the contracted work. Withdrawal from said account would require the
signatures of both parties.
t_tfit F OF CAS t FE_t..t 1 ION
You may cancel this transaction without penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any
payments made by you under the contract or sale, and any negotiable instruments executed by you will be returned within ten business days following receipt b
the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled If you cancel, you must make available to the
seller at your residence, in substantially as good condition as when received, any goods delivered to you under this contract of sale; or you may, if you wish,
comply with the instructions of the seller regarding the return shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the sellar does not pick them up within twenty days of the date of cancellation, you may retain or dispose o:
tine goods without further obligation. if you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then
you remain liable lbr performance of all obligations under the contract.
To cancel this transaction, mail or deliver a signed and dated copy of the cancellation note or ay other written notice, or send a telegram to Name of Seller, at
Address of Seller's Plane of Business not later than midnight of (date).
I .HEREBY CANCEL IBIS ".TRANSACTION. Buyer's Signature: __ ____ Date:
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The Commonwealth of Massachusetts
.`a
Department of Industrial: lccidents
i 1
Office of Investigations
listed on the attached sheet.
600 Washington Street
These sub -contractors have
Boston MA 02111
workers' comp. insurance.
www.►nass.gov/dia
Workers' Compensation Insurance ,affidavit: Builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
Namelllttsincss;(>rlzluniiati"Ii ln(liNiklual):yf X07111
;address:
City; StaterZip:�r�� 03D7 j Phone #:
,ire you an employer? Check the appropriate box:
1. [.I am a employer with
4. [1I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, j 1(4), and we have no
insurance required.] r
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I LE] Plumbing repairs or additions
12.❑ Roof repair_s/
13.XOther 57 7
`.any ,ipplicatit that checks box ? I must also tilt out the section below showing their workers' compensation policy intbnmtit) n.
+ I lomeowners who submit this aftidav it indicating they aro doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I um an employer that is providing workers' compensation insurance for my employees. Below is the policy unci job site
information.
Insurance Com an Name:_ -72
Policy '± or Self -ins. Lic.-`k:�-
K_V_ _
Expiration Date: //&? 7
Job Site Address: %fes �� City-State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 153 can lead to the imposition of criminal penalties of a
Fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP N1 ORK ORDER and a tine
Of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify untyVhe pains and penalties of perjury that the information provided above is true and correct
si"n;
Phone '
!Yjichd use only. no twt write in this area, to be ,:wiupkted by cil►' or rows official.
City or Tow n:
1'a.rmit/License #
0
issuing Authority (circle one):
1. board of Health 2. Building Department 3. City/Town Cleric d. E?ectrical inspector 3. F`lumbing inspector
6. Other
0)ntact Person:
Phone #:
Building Setback (tI.)
Front Yard
Side Yard
Rear Yard
Required
Pro% ided
Required
Provides
Required
Provided
DINIENSIOV
Number of Stories: Total square; feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
Workers Comp Affidavit
Photo Copy Of H.I.C. And/Or C.S.L. Licenses
Copy of Contract
Floor Plan Or Proposed Interior Work
Addition Or Decks
Building Permit Application
Surveyed Plot Plan
❑ Workers Comp Affidavit
J Photo Copy of H.I.C. And C.S.L. Licenses
:3 Copy Of Contract
❑ Floor Of Contract/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulil
Calculations (If Applicable)
Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
Building Permit Application
Certified Proposed Plot Plan
Photo of H.I.C. And C.S.L. Licenses
Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
Mass check Energy Compliance Report
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of
%ppeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One COP and
proof of recording must be submitted with the building application
OFT tR] ME`..'t':ilPF0R"05
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